Assessment of risk factors

Historical variables, clinical features since final inpatient admission, and details about care after inpatient discharge
(aftercare). Care variables included components of care at the time of suicide, decreases in care (decrease in frequency of
follow up and drug dosage, transfer to a setting with less observation, and discharge from follow up), and corresponding increases
in care. Predictable risk (risk of suicide perceived by a clinician at the last contact before suicide) was rated independently
by 2 psychiatrists blinded to case or control status.

Main outcome measure

Main results

The historical and clinical variables that were most strongly associated with suicide were index admission as the first psychiatric
admission, history of self harm, and suicidal thoughts during aftercare. These risk factors and depression in the 3 months
before suicide were also associated with each other, and therefore adjustment was made (table). Predictable risk rated as
moderate or high was not associated with suicide after adjusting for main risk factors. Patients who committed suicide were
more likely to have had a decrease in care at their final appointment (table).

Conclusion

In people with severe mental illness who commit suicide, certain clinical features and historical variables were associated
with suicide, including a decrease in care at their final appointment before death.

Commentary

Identifying people at high risk of suicide and reducing the numbers at risk are high priorities for mental health professionals
in many countries. This case control study by Appleby et al permits examination of the relation between mental health service provision and suicide.

The sample of people who committed suicide and their matched controls were drawn from discharged psychiatric inpatients in
Greater Manchester, UK. In a 30 month period, 708 overall confirmed or probable deaths occurred from suicide; of these, 149
suicides occurred in people who had had psychiatric hospital admissions within the previous 5 years. The authors used a model
that linked risk of suicide to specific clinical predictive factors. The predictable risk of suicide, defined as risk as it
would have been perceived by a clinician at the last contact before suicide, was independently assessed by review of clinical
notes by 2 psychiatrists who were unaware of which patient was a case and which was a control. The authors acknowledged the
limitation of using clinical notes but also took steps to address factors that might have confounded their findings.

The results are relevant to psychiatric and mental health nurses who work in clinics, outpatient or day care programmes in
the community, and hospitals. The age range of the patients was 16–93 years (median 38 y). Because those at highest risk for
suicide tend to be young men and elderly men, these findings are also important to nurses working with adolescent and elderly
populations. The finding critical to clinicians is that there was more likely to have been a decrease in care at the time
of the last appointment for those who committed suicide. This has important implications for practice.

Study findings suggest that clinicians maintain the intensity of aftercare for up to 1 year after hospital discharge, even
beyond perceived clinical recovery. In light of our current inability to identify those at highest risk of suicide, this study
also has implications for administrators to support aftercare programmes. Researchers need to continue to identify those aftercare
factors that may be part of the multifaceted approach needed to make a difference.